A recent British Medical Journal addressed the issue of whether doctors have an obligation not only to tell each other about potential conflicts of interest, but also their patients.
http://www.bmj.com/content/348/bmj.g259
http://www.bmj.com/content/348/bmj.g167

This applies to compensation received from drug and medical device companies, as well as to larger issues of payment--for example, whether the doctor is paid fee-for-service and therefore paid more to do more.

A few colleagues (including Costs of Care Founder Neel Shah) and I started the Who's My Doctor campaign as a first step towards transparency and accountability: http://whosmydoctor.com/. We believe that being honest with our patients improves trust, and strengthens the patient-provider relationship.

What do you think? Do patients have a right to know how their doctors are paid? How should this information be communicated?

 
A/Prof. Terry HANNAN
Replied at 5:21 PM, 29 Jan 2014

Amongst the vitriol against colleagues [Wen] as well as 'holding the fort' by certain colleagues regarding financial disclosures with potential conflicts of interest we now have an added component (It was always there) to the complex information management overload relating to "patient care". [Stead WW, Starmer JM. Beyond Expert-based Practice. Institute of Medicine (IOM) 2008. Evidence-Based Medicine and the Changing Nature of Health Care: . 2007 Annual Meeting Summary, Washington, DC: The National Academies Press, pp 94-105. 2008.]
There continues to be ethical/doubtfully ethical/unethical relationships between the industries that support clinical care and so as individuals the boundaries will remain blurred between what is right, wrong and financially rewarding as well as having political implications. [See the film "Fire In the Blood"].
Therefore IN ADDITION to designing and implementing adequate clinical decision support tools [L. Weed, Medicine In Denial, E. Topol, The Creative Destruction of Medicine] we need to design and implement e-tools that will make the financial alliances of clinicians 'automated' so that they are readily available to all who should see them and allow the clinicians to manage the rest of the information for better care. I hope I am not going around in intellectual circles here!!!

Kenneth Croen
Replied at 5:33 PM, 29 Jan 2014

Conflict of interest is a longstanding concern in healthcare as it relates to drug company money. It is now becoming more pervasive in the form of global capitation in the ACO model. Under this model, doctors will be paid a bonus if they spend less than allotted for the care of their population of patients. Physicians will be using ACO guidelines to limit patient access to care. The conflict of interest associated with drug company money involves a small percentage of all physicians, However, all ACO physicians will be eligible for bonuses and the drive to save money will be relevant in virtually every patient encounter.

Attached resource:

Elizabeth Glaser
Replied at 6:31 PM, 29 Jan 2014

The sunshine act put a lot of the reporting burden on pharmaceutical companies and manufacturers. That is not unreasonable, but there is also a case to make that the person receiving the payments should also be required to report and post this information in their office. For some people, it would not change who they see for care, but for other people, it might. But as one who receives care, I would be interested in knowing what payments my MD or NP receives. Imagine what might come along with such disclosures - it could really foster rich conversations on this subject.

Elizabeth

Thomas Tsai
Replied at 11:36 AM, 30 Jan 2014

Transparency is an important step, but as the evidence from public reporting of hospital outcomes would suggest, the impact on improving outcomes may be actually very limited.

Its also important to distinguish the reasons we feel that conflicts of interests are an issue, and clarifying the different reasons therefore would lead to different interventions. The two main concerns around conflict of interests are prices and harm--prescribing expensive branded medications and/or unnecessary medications that lead to patient safety issues. If the concern is that doctors are prescribing branded medications (because of honoraria they are receiving etc) contributing to higher costs of care, the problem then would not be the actual act of prescribing a medication, but that fundamentally the drug prices are too high. The focus therefore should be why drug prices in the US are 5-117% higher than other OECD countries. Drug prices are not set by physicians but by pharmaceutical companies. Transparency on physician conflicts of interests here would do little to move the needle on health care costs. What's needed is transparency on how drug prices are set in the US vs. the rest of the world.

Similarly, its unclear that disclosures around physician fee-for-service payments will accomplish much, seeing as the majority of physicians (or groups that employ or salary physicians) are still reimbursed fee-for-service. Capitated models have just as many quality concerns (underuse) as fee-for-service models (overuse). If the goal is to really focus on physician payment reform as a catalyst towards a value-based health care system, the burden should be on the actual payers, the insurance companies. There are many innovative ways around bundled payments and other value-based reimbursement approaches that payers are devising to reduce health care costs while improving quality. Efforts at disclosures should therefore be aimed at the payers, not just the providers. Here's an example--if someone gets into an accident because of a faulty traffic light, the problem isn't the driver, it's the faulty traffic light. Would it be more helpful to disclose how many times the traffic light stopped working or how many times an individual driver got into an accident because of a broken traffic light? We need to fix the incentives in health care and focusing on physicians alone shines a light on the symptoms, but ignores the underlying disease.

Mighty Casey
Replied at 11:57 AM, 30 Jan 2014

This is such an important issue. I agree with Thomas Tsai that attacking the symptoms (pharma/clinician fiduciary relationships) doesn't really attack the underlying condition: how payers control and influence every part of the healthcare system. This is particularly problematic in the US, since we're so wedded to fee-for-service that even in the rise of what's supposed to be a fix - ACOs and bundled payments - there's no real fix. It's just shifting things around.

I really see patients as the group that can help shift the shifters IF, and only if, they recognize their own power. Given the common perception that one is stuck with what your payer says you can access, care-wise, that's a big "if." I'm part of a growing group of expert (and loud-mouthed) patients who are pushing on the payer side of the equation to be more open-kimono on what they pay who for, and how much. Time for the Great and Powerful Oz to step out from behind the curtain. Patients can be Toto in that scenario by just pushing for access to payment info, and asking clinicians to join them in that disclosure push.

"How much is that" is a powerful question, if we just keep asking it ...

A/Prof. Terry HANNAN
Replied at 3:22 PM, 30 Jan 2014

Thomas, I enjoyed this posting. I am attaching a pdf of slides with explanations provided to me by John Wennberg that include discussions on fee-for-service and why current finding models fail to address costs and quality.
In a previous posting I recommended the documentary "Fire In the Blood" to see the enormous power across the whole social spectrum of pharmaceutical companies. Terry
[PDF with permission and full acknowledgment of Dr John Wennberg]

Attached resource:

Neel Shah
Replied at 3:48 PM, 30 Jan 2014

I appreciate Tom's insightful comments, which I agree with whole-heartedly. It is important to delineate between price and harm (or even price and utilization) since clinicians rarely set prices from the bedside. I also agree that physician disclosure is important, and perhaps plays a role in building patient trust (as Leana has argued) but may play a limited role in improving value without other systemic changes.

The question for Leana may be, would a campaign like Who's My Doctor have more legs if it specifically focused on certain types of potentially harmful industry associations rather than aiming to be comprehensive? And if so, what would these be? On the flipside, how can a physician responsibly disclose legitimate associations with industry without eroding patient trust?

Not sure if you all are following Paul Levy's battle with the University of Illinois - but it is very apropos to this discussion:
http://runningahospital.blogspot.com/2014/01/in-illinois-silence-is-deafening...

Attached resource:

Elizabeth Glaser
Replied at 3:59 PM, 30 Jan 2014

Bundled payments and ACOs are not particularly innovative , they are repackaging of older concepts. They could work in conjunction with other changes, but if bundled payments had been set according to the costs of best practices, not of typical care, then it could have really been innovative by linking clinical and fiscal benchmarks for quality and price in one package.

Having done clinical work and now research in policy, it is my opinion that insurance companies , at least in Massachusetts, are far less of an issue than the magical mystery tour between pharma, providers, and consumers. Massachusetts insurance companies set reasonable criteria for drugs in order to balance care and costs - but if a patient wants a drug, the physician prescribes it, sometimes even when it is not in the bests interests of the patient, the insurance company refuses to cover the drug for good clinical reasons, the physician blames the insurance company , and then consumer sees the insurer as the bad guy.

We seem to have a well of distrust in which some people distrust insurance companies , some distrust pharma , some patients distrust physicians etc. In insurers may block access to care, physicians block access to care for some and create markets for unnecessary procedures for others; as consumers we avoid taking responsibility for our health by taking the pharma opt out rather than trying to change our eating habits and lifestyle factors. And pharma, well... So we all have responsibility in improving our health and the health care system. Asking who, what, when, where, why , and "how much?" is one place to start.

Elizabeth

Leana Wen
Replied at 4:57 PM, 3 Feb 2014

Thanks, everyone, for the excellent comments. Apologies for my late response.

Kenneth: agree that there many types of COI. Disclosure can at least bring them out into the open.

Elizabeth: 100% with you that Sunshine Act will be helpful, but only if the info is available and accessible to patients. That’s why I started Who’s My Doctor—at least it’s one way for doctors to begin telling patients about COI.

Thomas: incentives are a major problem. I spoke about it recently:
http://www.youtube.com/watch?v=xKSWaCt3fqM
One way to change incentives is for providers and patients to demand a better way. And it brings increased trust to the doctor-patient relationship.

Casey: great to see you here!

Terry: thanks for the links.

Neel: the medical-industrial complex is pervasive and there are many parts that we can target—ACOs, insurance companies, pharma, pick your poison. Another way is to target the stakeholders, and emphasize that it really is about the primacy of the doctor-patient relationship. Let’s get that right, and let’s increase trust and transparency there as a start. What do you think?

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